Updated Guideline on the Use of Antiemetics to Prevent Vomiting and Nausea after Chemotherapy and Radiation Issued

The American Society
of Clinical Oncology has
issued an update to its clinical practice
guideline on the use of antiemetic
medications to prevent vomiting and
nausea resulting from treatment with
chemotherapy or radiation. The new
guideline includes comprehensive,
stratified recommendations on the use
of antiemetics during treatment with
chemotherapy drugs that are classified
as high, moderate, minimal, and low
risk for causing vomiting and nausea.

The updated guideline, American
Society of Clinical Oncology Clinical
Practice Guideline Update on Antiemetics,
was published in the Journal
of Clinical Oncology. The new recommendations
were developed by ASCO’s
Antiemetics Guideline Panel and are
based on a systematic review of new
and existing medical literature.

More than half of all people with cancer
experience nausea or vomiting during
the course of their treatment. If nausea
or vomiting becomes severe enough,
dehydration and other health problems
can occur. In some cases, these side effects
can cause cancer treatments to be
delayed, halted, or changed, which may
have a detrimental effect on overall treatment
outcomes. In the past two decades,
newer approaches and better antiemetic
medications have reduced the
incidence of both nausea and vomiting
in people undergoing cancer therapy.

More than half of all
people with cancer
experience nausea or
vomiting during the
course of their treatment.

“Antiemetics serve a vital role in reducing
the risk of nausea and vomiting
in cancer care, and when used appropriately,
can vastly improve patients’
treatment experience and enable them to
carry on with their lives,” says panel cochair
and study author Ethan Basch, md,
associate attending physician at Memorial
Sloan-Kettering Cancer Center in
New York, NY. “Over the past two decades,
major strides have been made
in recognizing the scope of this problem.
There have been improvements in
stratifying the risk of side effect risks
according to the type of drug treatment
used. This guideline update reflects
further progress refining antiemetic
approaches and minimizing these
side effects.”

The guideline provides detailed information
about the risk of vomiting
and nausea associated with various anticancer
agents and radiation therapy, as
well as the specific recommended antiemetic
regimens for each. Dr. Basch
points out that a major goal in cancer
care is to personalize therapy to each
individual, and that this guideline helps
physicians do so by stratifying each
person’s antiemetics needs based on
his or her particular treatments.

One key recommendation in this
update is the reclassification of the
risk for vomiting and nausea from the
combination of an anthracycline and
cyclophosphamide, a commonly used
chemotherapy regimen. Each drug alone
is classified as having a moderate risk,
but based on continued scientific data,
the combination now is considered highrisk.
This chemotherapy combination is
widely used in people with breast cancer
and non-Hodgkin lymphoma. This
change is significant because of the widespread
use of this combination, and the
potential to improve the individual’s
experience during treatment and avoid
treatment delays or dose reductions.

In addition, the guideline provides
direction on the use of fosaprepitant,
a relatively new intravenous formulation
of aprepitant. Data suggest that fosaprepitant
is equivalent to aprepitant in terms
of control and prevention of nausea and
vomiting. However, fosaprepitant is given
for one day, while aprepitant is given
for three days to people undergoing
chemotherapy that present a high risk
of vomiting and nausea. This may represent
a more convenient or feasible
option for some people. These drugs
are part of the guideline-recommended
three-drug combination (which includes
a 5-HT3 receptor antagonist and the
corticosteroid dexamethasone) for everyone
who receives high-risk chemotherapy.

“In general, we have more effective
and better tolerated antiemetic agents
today, and we have also learned how
to use the available agents in more
effective ways,” says panel cochair
Gary Lyman, md, mph, professor of
medicine at Duke University and the
Duke Cancer Institute in Durham, NC.
“Overall, oncologists have a better understanding
and an increasing number
of tools to reduce the side effects of
cancer treatment. In addition to better
strategies for preventing vomiting,
we’ve made tremendous progress in preventing
infection and managing pain, as
well as addressing the psychological
and emotional challenges of cancer.”

Some of the guideline’s other recommendations
include the following:

For people who receive chemotherapy
with a moderate risk of causing nausea
and vomiting, the two-drug combination
of palonosetron and dexamethasone is
recommended. If palonosetron is unavailable,
a first generation 5-HT3 serotonin
antagonist may be substituted.

For chemotherapy agents that carry a
low risk of inducing vomiting or nausea,
the panel recommends a single dose of
dexamethasone prior to chemotherapy.
It recommends that no antiemetic agent
be routinely given before or after chemotherapy
to prevent nausea or vomiting
brought on by minimal-risk chemotherapy
drugs.

For people who receive high-risk radiation
therapy, the panel recommends
that they receive a 5-HT3 antagonist before
each radiation fraction, and at least
24 hours after completing radiation therapy.
They should also be given a five-day
course of dexamethasone during fractions
one to five.